415600026-4-9-2026-14-AS-JVAO-DSYQXB-20260409123312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600026
Report Date: 04/09/2026
Date Signed: 04/09/2026 12:33:35 PM

Document Has Been Signed on 04/09/2026 12:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ROBERTA HOME		FACILITY NUMBER:	415600026
ADMINISTRATOR/ DIRECTOR:	PALERACIO, ALICIA		FACILITY TYPE:	735
ADDRESS:	1655 ROBERTA DRIVE		TELEPHONE:	(650) 341-4996
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 6		CENSUS: 5	DATE:	04/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Caregiver - Jay Baris		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/09/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with staff person Jay Baris. Around 1145am during the visit Marievic Dumlao, house manager, arrived to meet with LPA. During today's visit there is one client present and two staff. LPA was allowed entry into the facility. This is a single story facility. The facility is licensed for ages 18 though 59. All may be non-ambulatory. Facility is cleared for two hospice clients. There are no clients on hospice during today's inspection. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer. Medications are observed to be locked in a cabinet as well in the kitchen. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the backyard under a sheltered awning for client frozen supplies. There are additional emergency food supplies in the garage in a cabinet for client and facility use. Cleaning supplies are observed to be locked in a large white storage area in the backyard. First aid kit is observed as complete with required items stored with the medications. LPA observed that there are three fire extinguishers in place last inspected 03/04/2026, smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility smoke detectors are hard wired, and central heating system including AC units and fans in client bedrooms. Fire panel is observed in the garage. Facility is also equipped with fire alarm pull station near the front door. PPE and additional food supplies are observed as in place in storage shed and in the facility. Continued on next page...

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ROBERTA HOME	FACILITY NUMBER: 415600026
	VISIT DATE: 04/09/2026

NARRATIVE

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Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 106F in a common bathroom in the rear of the facility. Client room in the front of the facility contains a full bath but the shower is not used according to staff. Water temp is tested at 108F in this bathroom. Another bathroom is also in the front of the facility for client use with water temperature of 105F. LPA observed client rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Client linen supplies are observed as in place. There is one staff room assigned to the facility. LPA observed the backyard as containing a hospital bed with other miscellaneous materials on top of it. According to staff this is going to be removed in the coming weeks as well as some paint cans observed near a shed. Shed is observed with a couch as well as boxes of extra client supplies. According to staff Jay Baris, this area is not lived in and is only used for storage.

During today's visit LPA reviewed 4 client and 4 staff files of which all are current. Facility does handle client P&I. This is audited and is current based on count and P&I log and physical count. Client medications are reviewed and are current per medications administration record. Last disaster drill conducted on 03/28/2026. Administrator certificate is observed as current expiring 03/17/2027

The following updated forms are requested to be submitted to CCLD by 04/16/2026:

• Copy of updated Administrator Certificates
• Copy of facility's liability insurance
• LIC500 Staff Schedule

No citations are issued on this day. LIC9102TV issued. Report is reviewed with house manager Marievic Dumlao.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC809 (FAS) - (06/04)

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